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To the Editor: In their study of quality improvement strategies for type 2 diabetes, Dr Shojania and colleagues¹ found that most strategies produced at best modest improvements in glycemic control but that case management in which a nurse or pharmacist could make independent medication changes was associated with substantially greater improvements compared with any other strategy.

The authors may have inadvertently underestimated the strength of this important finding. Our study of case management² was a large trial with negative results, and it was included among the 11 studies in which case managers could make independent medication changes. However, although our case managers were nurse practitioners who had prescriptive privileges, our agreement with the participating primary care physicians did not allow the case managers to directly make any medication changes. We believe that this was a major reason that we did not achieve the level of benefit found in our other . . . [Full Text of this Article]

Sarah L. Krein, PhD, RN
skrein@umich.edu

Sandeep Vijan, MD, MS
Center for Practice Management and Outcomes Research
VA Ann Arbor Healthcare System
Ann Arbor, Mich

Hae Mi Choe, PharmD, CDE
College of Pharmacy
University of Michigan
Ann Arbor

Rodney A. Hayward, MD
Center for Practice Management and Outcomes Research
VA Ann Arbor Healthcare System

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Quality Improvement Strategies for Type 2 Diabetes
Michael Pignone and Darren DeWalt
JAMA. 2006;296(22):2680-2681.
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Quality Improvement Strategies for Type 2 Diabetes—Reply
Kaveh G. Shojania, Sumant R. Ranji, Kathryn M. McDonald, Jeremy M. Grimshaw, Robert J. Rushakoff, and Douglas K. Owens
JAMA. 2006;296(22):2681.
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